Comparison between Protocols for Management of Fetal Growth Restriction

Leal, Caio Ribeiro Vieira; Rezende, Karen Pereira; Macedo, Evilane do Carmo Patrício de; Rezende, Guilherme de Castro; Corrêa Júnior, Mário Dias

doi:10.1055/s-0043-1764493

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Revista Brasileira de Ginecologia e Obstetrícia

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Review Article • Rev Bras Ginecol Obstet 45 (2) • Feb 2023 • https://doi.org/10.1055/s-0043-1764493 copy

Comparison between Protocols for Management of Fetal Growth Restriction

Comparação entre protocolos de acompanhamento da restrição de crescimento fetal

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

This comprehensive review compares clinical protocols of important entities regarding the management of fetal growth restriction (FGR), published since 2015. Five protocols were chosen for data extraction. There were no relevant differences regarding the diagnosis and classification of FGR between the protocols. In general, all protocols suggest that the assessment of fetal vitality must be performed in a multimodally, associating biophysical parameters (such as cardiotocography and fetal biophysical profile) with the Doppler velocimetry parameters of the umbilical artery, middle cerebral artery, and ductus venosus. All protocols reinforce that the more severe the fetal condition, the more frequent this assessment should be made. The timely gestational age and mode of delivery to terminate the pregnancy in these cases can vary much between the protocols. Therefore, this paper presents, in a didactic way, the particularities of different protocols for monitoring FGR, in order to help obstetricians to better manage the cases.

Keywords
Fetal growth restriction; Doppler velocimetry; Prematurity; Cardiotocography; Protocols

	FIGO¹1 Melamed N, Baschat A, Yinon Y, et al. FIGO (international Federation of Gynecology and obstetrics) initiative on fetal growth: best practice advice for screening, diagnosis, and management of fetal growth restriction. Int J Gynaecol Obstet. 2021;152(01):3–57. Doi: 10.1002/ijgo.13522 https://doi.org/10.1002/ijgo.13522...	ISUOG²2 Lees CC, Stampalija T, Baschat A, et al. ISUOG Practice Guidelines: diagnosis and management of small-for-gestational-age fetus and fetal growth restriction. Ultrasound Obstet Gynecol. 2020;56(02): 298–312. Doi: 10.1002/uog.22134 https://doi.org/10.1002/uog.22134...	SMFM³3 Martins JG, Biggio JR, Abuhamad ASociety for Maternal-Fetal Medicine (SMFM). Electronic address: pubs@smfm.org. Society for Maternal-Fetal Medicine Series #52: diagnosis and management of fetal growth restriction: (Replaces Clinical Guideline Number 3, April 2012). Am J Obstet Gynecol. 2020;223(04):B2-–B17. Doi: 10.1016/j.ajog.2020.05.010 https://doi.org/10.1016/j.ajog.2020.05.0...	FCOG⁵5 Vayssière C, Sentilhes L, Ego A, et al. Fetal growth restriction and intra-uterine growth restriction: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians. Eur J Obstet Gynecol Reprod Biol. 2015;193:10–18. Doi: 10.1016/j.ejogrb.2015.06.021 https://doi.org/10.1016/j.ejogrb.2015.06...	ACOG⁶6 Fetal Growth Restriction. Fetal Growth Restriction: ACOG Practice Bulletin, Number 227. Obstet Gynecol. 2021;137(02):e16–e28. Doi: 10.1097/AOG.0000000000004251 https://doi.org/10.1097/AOG.000000000000...
If no changes in Doppler	Doppler every 1-2 weeks	–	Doppler weekly	Doppler every 2-3 weeks	–
If early doppler changes (IP UA >p95 or IP MCA <p5)	Doppler 1-2 times a week and BP twice a week	–	Doppler weekly	Doppler weekly	–
If AEDF-UA	Doppler 3 times a week and BP daily	Doppler 2-3 times a week	Doppler 2-3 times a week and CTG daily	Doppler more than once a week and CTG daily	–
If REDF-UA	Doppler daily and BP twice a day	Doppler 2-3 times a week	CTG daily	Doppler more than once a week and CTG daily	–
If ductus venosus alteration (PI> p95, absent or reversed A wave)	Doppler daily and BP twice a day	–	–	–	–

	FIGO¹1 Melamed N, Baschat A, Yinon Y, et al. FIGO (international Federation of Gynecology and obstetrics) initiative on fetal growth: best practice advice for screening, diagnosis, and management of fetal growth restriction. Int J Gynaecol Obstet. 2021;152(01):3–57. Doi: 10.1002/ijgo.13522 https://doi.org/10.1002/ijgo.13522...	ISUOG²2 Lees CC, Stampalija T, Baschat A, et al. ISUOG Practice Guidelines: diagnosis and management of small-for-gestational-age fetus and fetal growth restriction. Ultrasound Obstet Gynecol. 2020;56(02): 298–312. Doi: 10.1002/uog.22134 https://doi.org/10.1002/uog.22134...	SMFM³3 Martins JG, Biggio JR, Abuhamad ASociety for Maternal-Fetal Medicine (SMFM). Electronic address: pubs@smfm.org. Society for Maternal-Fetal Medicine Series #52: diagnosis and management of fetal growth restriction: (Replaces Clinical Guideline Number 3, April 2012). Am J Obstet Gynecol. 2020;223(04):B2-–B17. Doi: 10.1016/j.ajog.2020.05.010 https://doi.org/10.1016/j.ajog.2020.05.0...	FCOG⁵5 Vayssière C, Sentilhes L, Ego A, et al. Fetal growth restriction and intra-uterine growth restriction: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians. Eur J Obstet Gynecol Reprod Biol. 2015;193:10–18. Doi: 10.1016/j.ejogrb.2015.06.021 https://doi.org/10.1016/j.ejogrb.2015.06...	ACOG⁶6 Fetal Growth Restriction. Fetal Growth Restriction: ACOG Practice Bulletin, Number 227. Obstet Gynecol. 2021;137(02):e16–e28. Doi: 10.1097/AOG.0000000000004251 https://doi.org/10.1097/AOG.000000000000...
EFW p3-p10, no changes on Doppler (SGA)	37 to 39 weeks	38 to 39 weeks	38 to 39 weeks	–	38 + 0 to 39 + 6 weeks
EFW <p3 (isolated FGR), no changes on Doppler	36 to 38 weeks	36 to 37 weeks	37 weeks	–	37 weeks
Early Doppler changes (PI UA >p95, PI MCA <p5, CPR <p5, mean PI UtA >p95)	34 to 37 weeks (including changes such as oligohydramnios and suboptimal growth)	36 + 0 to 37 + 6 weeks	37 weeks	–	–
AEDF-UA	32 weeks	34 weeks	33 to 34 weeks	–	–
REDF-UA	30 weeks	32 + 0 to 33 + 6 weeks	30 to 32 weeks	–	–
Changes in the ductus venosus (PI >p95, absent or reversed A wave)	26 weeks	26 weeks	26 weeks	–	–

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[1] Address for correspondence Caio Ribeiro Vieira Leal, Avenida Alfredo Balena, 110, 301130-100, Belo Horizonte, MG, Brazil. (e-mail: lealcaiorv@gmail.com).

1-STV Criteria
	a) STV <2.6ms between 26 + 0 and 28 + 6
	b) STV <3.0ms between 29 + 0 and 31 + 6
	c) Delivery regardless of STV if there are spontaneous, repeated and persistent decelerations in CTG
2- UA Doppler Criteria
	a) AEDF-UA above 34 weeks
	b) REDF-UA over 32 weeks
	c) Following local protocols, delivery could be performed if AEDF-UA above 32 weeks or REDF-UA above 30 weeks